Almost everyone engages, at least occasionally, in undesirable and unhealthy behaviors. Most people acknowledge at least some of their undesired behaviors and would like to change them, although success in doing so often remains elusive. Meanwhile, medical and psychological understanding of human behaviors and effective behavior management techniques have made significant advances in the last century. However, for any number of reasons, a great many people are unable to effectively access and use effective behavior management techniques which could significantly improve their quality of life.
For example, at any given time, about a quarter of individuals with diabetes has clinically significant depressive symptoms. Untreated depression adversely affects diabetes self-management and diabetes-related outcomes such as glucose and blood pressure control. Furthermore, people with diabetes commonly experience stress related to diabetes (e.g. dealing with symptoms, potential functional limitations and ‘24/7’ tasks required to manage diabetes), which is exacerbated when depression is present. However, many of the effects of depression on amplifying diabetes symptoms, reducing self-management capacity and disrupting interpersonal relationships are also seen in individuals with diabetes who are not (or not yet) depressed but who may be intermittently overwhelmed and burdened by managing diabetes and associated chronic illness (90% of individuals with diabetes have at least one other chronic condition).
Depression manifests much differently in individuals with diabetes compared to the way it manifests in individuals without diabetes. The concept of diapression is an approach that helps individuals with diabetes, their family members, and their clinicians gain a better understanding of the unique ways that stress, depression and diabetes interact. Diapression is a clinical conceptual framework that looks beyond the diagnoses of “diabetes” and “depression” toward a fuller appreciation of the experience of living with diabetes and other medical conditions in the presence of stress and depression, as described in Ciechanowski, P. S., “Diapression: An Integrated Model for Understanding the Experience of Individuals With Co-Occurring Diabetes and Depression,” Clinical Diabetes 2011 29 (2): 43-49.
The diapression approach addresses the adverse influence of stress and depression on:
Diabetes symptom perception (e.g. neuropathy pain)
Diabetes self-management and treatment adherence
Lifestyle habits (e.g. smoking, emotional eating)
Healthcare utilization patterns
Quality and effectiveness of social support networks
Trust, satisfaction, and communication effectiveness in healthcare relationships.
Such adverse influences are experienced even in individuals with diabetes who are only intermittently stressed or overwhelmed with diabetes. On one hand, approaches for managing these issues may be relevant for most individuals with diabetes; on the other hand, a primary focus on helping those who are most stressed or depressed ensures a broader population-based approach that doesn't exclude depressed, overburdened individuals, or individuals with higher levels of clinical complexity.
Potential benefits of the diapression approach include greater satisfaction with care, higher quality care, and better outcomes achieved at a potentially lower cost. In addition, benefits may specifically include:
Raised awareness of the presence of stress and depression in diabetes
Increased screening for, and recognition of depression in patients whose depression symptoms primarily manifest as amplified diabetes symptoms
Increased acceptance of a depression diagnosis and depression treatment by patients, their supports and their clinicians
Improved patient-provider communication
An evidence-based explanatory model for understanding worsening diabetes symptoms, lack of self-care, and increase in adverse lifestyle habits in the context of depression
A framework for understanding changes in healthcare use (e.g., missed visits)
While such potential benefits of the diapression approach are promising, with today's short health care visits and fragmentation of systems typical of some healthcare systems, it is important to develop tools to effectively help patients with behavior management (whether diabetes/depression related or otherwise) between and outside of healthcare visits. Increasingly, there is a greater emphasis on patients taking charge of their own health. Behavior change also occurs outside of the healthcare visit and between visits—therefore tools are needed to assist patients and healthcare providers in identifying and realizing positive behavioral changes. Such tools may be applied in healthcare as well as other systems such as education and organizational development.